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To: / /
Consumer Name (Print):
PCA Name (Print):
PCA Telephone #:
PCA Last 4 Digits of SSN
WEEK
#1
Time In
Sun.
Time Out Tot. Night Hrs
Midnight-6AM
Mon.
Tue.
Wed.
Thu.
Fri.
Sat.
By signing below, I certify under pain and penalty of perjury that I have received MassHealth PCA services
from the PCA during the times described on this activity form; and I am not enrolled in Adult Foster Care
and/or Group Adult Foster Care.
Payroll Period From: / /
Consumer Number:
TEMPUS UNLIMITED, INC., 600 Technology Center Drive, Stoughton, MA 02072
Toll-free Phone #: 1-877-479-7577 Toll-free Fax #: 1-800-359-2884
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Total Week 1
By signing below, I certify under pain and penalty of perjury that I have provided
MassHealth PCA services to the consumer during the times described on this
activity form.
:
Consumer/Surrogate
Signature
PCA
Signature
Tot.Day/Eve Hours
6AM to MidnightHRS MIN. HRS MIN. HRS MIN. HRS
WEEK
#2
Time In
Sun.
Time Out Tot. Night Hrs
Midnight-6AM
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Sat.
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Total Week 2 :
Tot.Day/Eve Hours
6AM to MidnightHRS MIN. HRS MIN. HRS MIN. HRS
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Telephone #:
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Please note that Tempus pays the PCA
based on daily, not weekly, totals.
Please note that Tempus pays the PCA
based on daily, not weekly, totals.
1
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